1. Transitions between the Criminal Justice
System and the Community:
Implications for Health
Ingrid Binswanger, MD, MPH
Assistant Professor, Division of General Internal Medicine
and Division of Substance Dependence
University of Colorado Denver School of Medicine
University of Pennsylvania
May 8, 2009

2. Goals
1) Understand the scope of the criminal justice
system in the US
2) Examine death rates and causes of death
among former inmates
3) Describe risk factors for death after release
from prison
4) From 30,000 to 30: Preliminary qualitative
data on health needs of former inmates
5) Implications for public health

3. 1) Scope of the Criminal Justice
System
3% US adults in jail, prison,
probation or parole
1.5 million children with a parent in
prison - 7% of African American
children
Bureau of Justice Statistics, 2007, 2008

4. General Population
Communities/families
affected by
incarceration
Previously
incarcerated
Probationers
and parolees
Current jail
and prison
inmates
The ecology of incarceration and health

5. Growth in the criminal justice system
 Number of prisoners
 Year-end 1980: 300,000
 Year-end 2006: 1.3 million
 Spending on corrections
 1987: $12 billion
 2007: $47 billion
The PEW Center on the States, 2008

6. High Disparities: Projected Percent of
Men who will go to Prison
6%
17%
32%
0
5
10
15
20
25
30
35
40
African American Latino White
95% will be released
Percent
Bureau of Justice Statistics, 2003

7. 2) Mortality after release from prison:
Aims
1. What are the death rates after release
from prison?
2. What are the major causes of death after
release?
3. How do the death rates among former
inmates compare to those of the general
population?
Binswanger, Stern, Deyo, et al., NEJM 356:157-65, 2007

8. Study methods
 Retrospective cohort study
 Participants
 All released inmates from Washington
State Department of Corrections
 30,257 followed for 57,049 person-
years
 July 1999-December 2003
Binswanger, Stern, Deyo, et al., NEJM 356:157-65, 2007

9. Data sources
1. Washington State Dept. of Corrections
2. National Death Index-Plus, CDC
3. CDC Wonder

10. Data analysis
1. Mortality rates
 Deaths/person-time at risk out of prison
after release
 Data censored at date of death, end of
study, or date of re-incarceration if not
released again
 If re-incarcerated, time back in prison did
not count towards person-time at risk
1. Relative risks
 Compare mortality rates among released
inmates to other WA state residents
 Poisson regression adjusted for age, gender
and race

11. 30,257 followed for 57,049 person-years
30,636
150 Incomplete data
Ineligible and excluded: 1%
Deaths excluded:
144 Prison deaths & executions
30 Death & prison dates inconsistent
5 Releases for grave medical illness
50 Age<18

12. Demographic characteristics
N=30,257
Age, mean years (SD) 33 (10)
Male 87%
Race/ethnicity
White, non-Hispanic
African American, non-Hispanic
Latino/Hispanic
Native American/Alaska Native
Asian/Pacific Islander
61%
20%
13%
4%
2%

13. Deaths after release
N=30,257
 443 deaths
 Mean time at risk out of prison: 2 years
 Mean age at death: 42

14. Mortality rates
Deaths/100,000
person-years
Released inmates 777
In WA prison 201
Other Washington
residents*
223
*Adjusted for age, gender and race

15. Elevated mortality rates
in first 2 weeks after release
0
1000
2000
3000
0
-2
3
-4
5-6
7-8
9+
O
verall
Weeks since release
Deaths
/100,000
person
years
Adj. WA
state=223

16. Leading causes of death
n=443
*Compared to other Washington State residents,
adjusted for age, gender and race
No.
Relative
Risk*
Drug overdose 103 12.2
CV disease 57 2.1
Homicide 55 10.4
Suicide 41 3.4

17. Drug overdose deaths (n=103)
0 10 20 30 40 50 60
Multiple
Other opioids
Other narcotics
Benzodiazepines
Tricyclics
Alcohol
Methadone
Heroin
Psychostimulants
Cocaine
Number of deaths

18. Other causes of death
n=443
No.
Relative
risk
Cancer 39 1.7
Motor vehicle accident 35 3.4
Liver disease 23 4.7
*Compared to other WA residents, adjusted for age, gender
and race

19. Cancer deaths after release (n=39)
0 5 10 15 20
Stomach
Renal
Prostate
Liver
Pancreatic
Lung
Number of deaths

20. Limitations
 Matching individuals with deaths
 Criteria for rejecting uncertain matches for
death
 Excluded some known deaths
 Cause of death data from death certificates
 Could not adjust for all socio-economic factors
 Single prison system in single state
 11.5 million releases from jails & prisons/ year

21. Rates and Causes of Death:
Conclusions
 Former inmates at high risk for death after
release
 Risk greatest in first 2 weeks after release
 Released inmates were at highest risk from
overdose, cardiovascular disease, homicide and
suicide
 Increased risk of death has also been shown in
European, Australia and confirmed in
subsequent US studies
Bird SM, 200; Hobbs M, 2006; Pritchard C, 1997; Verger P,
2003; Rosen DL, 2008

22. Examining Risk Factors: Methods
 Data on demographic factors, chemical
dependency and mental health
characteristics identified from administrative
data of DOC
 Cox proportional hazards regression used for
analysis
 All releases treated as independent
Collaborators: MF Stern, P Blatchford

23. Conceptual model:
Prisoner Re-entry and Health
Pre- incarceration
factors
Reentry
conditions
Incarceration
experience
Health
Outcomes
Modified from Gelberg L, 2000

24. Prisoner re-entry and health:
Non-modifiable Factors
Pre- incarceration factors
Race, age, gender, education, neighborhood, drug and alcohol
dependence, mental health disorders, risk behavior, exposure
to violence, access to health care
Reentry conditions
Transitional challenges, type of release, re-entry policies,
physiologic changes, access to health care,
prescriptions, drug treatment
Incarceration experience
Length of incarceration, quality of care,
preventive services, chemical dependency
treatment, psychiatric treatment
Health
Outcomes
Mortality

25. Characteristics (n=38,803) HR (95% CI)
Gender
Men
Women
1.0
0.8 (0.6, 1.1)
Age
Each decade increase, <50
Each decade increase, >50
1.6 (1.4, 1.7)
1.8 (1.4, 2.4)
Race
Non-Hispanic White
Non-Hispanic Black
Other
1.0
0.9 (0.7, 1.2)
1.0 (0.7, 1.4)
Hispanic 0.5 (0.3, 0.7)
Length of incarceration, years 1.0 (0.9, 1.0)
Release Status
Release without supervision
Release with supervision/ parole
Other
1.0
0.7 (0.6, 1.0)
1.4 (0.8, 2.5)

26. Characteristics
% or
median
HR (95% CI)
Drug Dependence
No
Yes
Missing
25%
48%
27%
1.0
1.4 (1.1, 1.8)
2.3 (1.8, 3.1)
Serious Mental Health Problem
No
Yes
Missing
49%
7%
44%
1.0
1.2 (0.9, 1.7)
0.3 (0.2, 0.4)

27. Risk Factors for Death: Conclusions
 Older individuals at higher risk for death
 Low mortality rates in Latinos
 Deaths that outside of the US?
 Socio-cultural factors?
 Different reasons for incarceration?
 Release with supervision mildly protective

28. Risk Factors for Death: Conclusions
 Chemical dependency is an independent risk
factor for death
 Missing chemical dependency screen
even more strongly associated
 Not having a mental health record is
protective factor
 Administrative correctional data have
substantial missing data on clinical factors

29. Risk Factors for Death: Conclusions
 The subset of inmates who were not
screened for chemical dependency deserves
closer attention
 If failure to be screened is a contributor to
increased death, greater screening for
chemical dependency in prison settings may
reduce the risk of death among former
inmates by increasing access to treatment

30. 4) From 30,000 to 30: Assessing the health
needs of former inmates
Known challenges faced by former inmates
 Legal identification
 Housing
 Employment
 Health care
 Parole conditions
 Drugs & alcohol
 Re-integration with families & communities
La Vigne, Castro, Vicher, 2004, Burgess-Allen, 2006,
Freundenberg, 2005

31. 4) From 30,000 to 30: Assessing the health
needs of former inmates
Aim:
Describe health-seeking experiences,
perceptions of risk, and health needs of
former prisoners during the transition from
prison to the community
Goal:
Learn how to reduce the risk of death from
former inmates

32. Health needs of former inmates: Methods
 Qualitative key informant interviews with 30
former prisoners within 60 days of release
 Recruitment: 2 medical clinics at Denver Health
with snowball sampling
 Interview topics
 Perceptions of risk to health and safety
 Gaining access to medical care
 How could health needs/safety be better
addressed
 Analysis: Team approach with member checking

33. Preliminary Results
 19 interviews completed
 X% white, Y% African American, X% Latino, Z
% American Indian
 X% female

34. Preliminary Results
 Early themes:
 Prison as a healthier environment than the
community
 Gaining access to health care after
release is high priority
 Direct experiences with friends who
overdosed after release from prison

35. Prison as a healthier environment than
the community
In all actuality, and a lot of people may take this
the wrong way, but prison can actually
preserve you. It can actually save you. I
mean if you were doing drugs – not to say
that there are not drugs in there, but they are
not in abundance, you know what I mean?
So what are you going to do if you can’t get
them you know? So you either quit or go
crazy.

36. Prison as a healthier environment than
the community
[about prison] You exercise. You use your
mind. You read. You work. You do everything
to improve your health. There’s no down side
to being in prison except for one thing. You
are isolated from women. Add women to
that, women in prison, and every man who
got a prison sentence I swear to god would
stay there. Do every day of his time.

37. Gaining access to health care after
release is high priority
[about priorities after release] You know you
get food stamps, you get other things when
you get out. But healthcare is one of the
main things you know? Your health is
everything. If you don’t have your health you
don’t have anything. If you don’t have your
health you can’t do nothing.

38. Experiences with overdose after
release
[Respondent] …I’ve lost quite a few friends that
have came out [of prison] and were very fresh
to this street life and they OD’d on heroin you
know. Just a sad thing. Of course they had only
been out a couple weeks.
[Interviewer] And how many times have you seen
or heard about that happening would you say?
[Respondent] Um…maybe 6 times...and then
there’s been others who have OD’d but not died
you know.

39. 5) Implications of for Public Health
Detrimental impact of transitions on
individual health
Morbidity and mortality after release
Multiple transitions in care
Secondary health effects of social and
economic factors related to conviction
Blankenship, et al., J Health Care Poor Underserved, 2005; Freudenberg, AJPH,
2002; Iguchi, Public Health Reports, 2002.

40. 5) Implications for Public Health
Detrimental effects on family/community health
Disruption of family, social and sexual networks
“Forced migration”
Transmission of sexually transmitted infections
Inter-generational health effects
Thomas, 2008; Clear in Greifinger, 2007

41. Recommendations
1. Measure health outcomes in criminal justice
populations
2. Include criminal justice involvement in broader
health research
3. Provide preventive care in criminal justice
settings
4. Reduce health disparities through
interventions in criminal justice system
5. Including correctional care in comprehensive
efforts at health care reform

42. Acknowledgements
John Steiner, MD, MPH
Jean Kutner, MD, MSPH
Marc Stern, MD, MPH
Patrick Blatchford, PhD
Susanne Felton, MA
Carolyn Nowels, MA
Robert Wood Johnson Foundation Physician Faculty Scholars
Program
Division of General Internal Medicine, University of Colorado
Denver School of Medicine
Washington Department of Corrections